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Recommendations for using MMR vaccine in children allergic to egg should be consistent
  1. F ANDREW I RIORDAN, Consultant Paediatrician
  1. Dept of Child Health
  2. Birmingham Heartlands Hospital
  3. Birmingham B9 5SS, UK

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    Editor,—Two reviews of measles, mumps, and rubella (MMR) vaccine and egg allergy have recently been published. One appears in the Royal College of Paediatrics and Child Health's own journal (Archives of Diseases in Childhood),1 the other has been endorsed by the Committee on Infection and Immunisation of the Royal College of Paediatrics and Child Health.2 The two articles differ in their recommendations of which children should be given MMR under supervision in hospital. Which of these expert opinions should paediatricians and general practitioners follow? Were the authors of the two articles aware of each others' conclusions? Could the editorial boards of the two journals (which have members common to both) not have informed the authors?

    These recommendations also differ from Department of Health advice,3 which also differs from that given by the Health Education Authority.4 This debate might be settled if a consensus can be agreed and published in the next edition ofImmunisation against infectious disease.3

    In the mean time a pragmatic approach is needed. That is to offer MMR under supervision in hospital to children who have had a severe allergic reaction to egg and to children whose general practitioners, practice nurses, or parents are unhappy for them to be given MMR elsewhere.

    References

    Dr Lakshman and Dr Finn comment:

    We note Riordan's response to our editorial on the issue of MMR vaccine and allergy1-1 and the recommendations put forward by Khakoo and Lack1-2 on this topic. While we agree that conflicting advice creates confusion, we cannot agree with his proposed “pragmatic approach”. This amounts to a pointless waste of time and resources—greater than that proposed by anyone else to date—which will simply stoke up unfounded concerns about this vaccine, while diverting people from the important necessity to prepare themselves to tackle cases of severe anaphylaxis which, on the rare occasions that they occur, will continue to do so in community clinic settings.

    References

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    Dr Marcovitch, Editor in Chief of Archives of Disease in Childhood, comments:

    Dr Riordan asks which expert opinion to follow. The answer surely lies in reading the papers carefully, seeking out any key references quoted, and deciding for oneself who has provided the best evidence. This should be the case for all guidelines, but we know that they are often absorbed undigested, which is one reason whyADC erects fairly firm barriers to their publication. Lakshman and Finn's paper was commissioned by the editors as a leading article because, as practising paediatricians, we recognised that all of us have problems responding logically to requests to immunise children in hospital.

    When we commissioned this paper we did not know that a college committee was embarking on an enquiry; we learned this only after our leading article had been peer reviewed and was set up for publication. Editors of ADC have long been saddened that many of our readers, including members and fellows of the RCPCH, prefer first to submit their papers elsewhere; we realise, of course, that the artificial constraints of the research assessment exercise result in some authors needing to collect Brownie points by publishing in journals with a higher impact factor, even if their research thereby reaches an inappropriate readership. In this sense, the BMJ is our competitor, not our partner, which is why editors do not tell each other what they have in the pipeline.

    I realise that this cannot have been the case in this instance as the BMJ copied Khakoo and Lack's paper from the specialist journal in which it originally appeared (which probably has a lower score than ADCand is read by far fewer paediatricians).

    Dr Riordan suggests seeking a consensus. Far better would be to undertake a full literature search of RCTs and subject it to a systematic review. The days of guidelines by GOBSAT(grand old boys sitting at table) are over. At this year's annual scientific meeting of the RCPCH, the journal and the college's quality of practice committee have forged a working relationship that should leave our readers less confused in future.

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